QSR Quaker Special Risk Exclusively serving retail agents since 1960
|
|
- Antonia Perkins
- 5 years ago
- Views:
Transcription
1 QSR Quaker Special Risk Exclusively serving retail agents since 1960 Masonry/Concrete/Plastering/Cement Contractors Specialty Trade Contractors Program Account Name Account Contact Name Producer Name Producer address Account web site address Account address Date Completed Proposed Eff. Date Form of Business: Individual Partnership Joint Venture Corporation Subchapter S Corporation LLC Years in business: Date of license: 1. Please attach a list of the risk s jobs (job list) for the last two years as well as a list of the jobs committed to for the next 12 months. 2. Risk is operating as: General Contractor ELIGIBILITY Prime Contractor Subcontractor _ 3. Enter the percentage of operations from the following? % s based on Sales Cost of Subcontractors Residential/Habitational _ Commercial _ Industrial Institutional Total 4. Indicate percentage in the following? New Construction Retrofit/Rehab Service Maintenance Other
2 5. Indicate percentage of electrical work in the following scope of operations/specialty, if applicable? Subs Sales Percentages based on: a. Pre-Cast Concrete b. Concrete Maintenance and Repair c. Concrete Paving (including ground supported concrete floors, driveways, sidewalks, curbs, gutter, patios) d. Concrete tilt-up construction e. Concrete Construction NOC f.. Flat Masonry g. Stucco/Plastering (non EIFS) h. EIFS i. Structural Masonry Receipts history, please provide receipts figures for the past 3 years: Please provide estimated receipts for the next 12 months: Payroll: Please provide payroll estimates for the next 12 months by ISO classification: 1. Masonry code Plastering/Stucco code Concrete code Other code 5. Contractors Subcontracted work code 91583/91585* *Cost of subcontractors includes BOTH labor & material Does the insured/risk perform construction operations involving any one of the following: Airport runway, warming apron construction or repair Asphalt and blacktop work Bridge or elevated highway Caisson or dam Concrete pumping operations
3 Industrial and chemical waste collection or sedimentation pond Plastering or stucco operations Pre stressed structural concrete Redi-mix operations, concrete or cement hauling for others Sand and gravel hauling for others Street or road construction Subway or tunnel construction Swimming pool construction Tilt-slab or tilt-up work in excess of 75 feet in height Sidewalks/curbs Free forming theme plastering Fireproofing Decorative/colored plastering/concrete Sealing/waterproofing Retaining walls Piers/wharves/docks/bulkheads/seawalls Pointing & restoration Foundation repair House/building raising 6. Other Operations? If yes, please describe: 7. Has the risk been cited for any OSHA violations? If yes, please explain further. 7a. Any policy coverage declined, cancelled or non-renewed during the prior 3 years? 7b. Has the applicant ever filed personal or corporate bankruptcy? 8. Does the insured communicate with the One-Call Service Center and the area utility owners that are not members of the One-Call Service Center prior to all scheduled excavation work? 9. Does the insured offer 24-hour emergency repair service? 9a. Any electrical disturbance testing services provided? If, please explain with full details. NA 9b. Any inspection services provided for code compliance? 10. Indicate the average percentage of the risk s TOTAL payroll or sales during the past 5 years for the following: Percentage based on: (Check One) HABITATIONAL WORK Payroll Subs
4 Please complete if the risk does any Habitational work. Habitational Work Breakdown % New or Major Rehab/Renovation + % Service or Maintenance = Condominium (High and % + % % Low Rise) Multi-Family Owned % + % % Developments (including townhouses) Tract Housing % + % % Triplexes and Duplexes % + % % Apartments % + % % Other % + % % 11. Does the risk have any future plans related to work involving new construction of condos, townhouses, tract homes? If, please describe. 12. List the states the insured worked in the last 5 years. 14. Has the risk ever been named in claims and/or litigation regarding faulty or defective construction or workmanship? If, was risk acting as a: What type of project? Provide detail on claim/litigation and how the issue was corrected. General Contractor Sub- Contractor Habitational Commercial 15. Does risk have knowledge of any pre-existing act, omission, event; condition or damages to any person or property that may potentially give rise to any future claim or legal action? If, please describe. 16. Any current or past involvement with wrap-up/ocip? Any residential wrap-ups? 17. Does the risk have a quality control program? Attach a copy of Table of Contents If, is it? Informational Documented 18. Does the risk retain job files? If, how long are they retained?
5 Any past, present or future work in NY city boroughs of Manhattan, Brooklyn, Bronx or Queens? If, please supply separate sheet detailing past 5 jobs & open bid work in the boroughs including location, description or work, duration of job, contract amount and number of stories for any exterior work. Do you work as a real estate developer? Any past, present or future work on landfill areas or in subsidence areas? Any subsidence or sinkhole related losses in the last 5 years? Any exterior work in excess of 4 stories? If, what is the percentage of work over 4 stories? Any past, present or future work performed below grade? If, what maximum depth: 19. List the types of work subcontracted Does risk obtain certificate of insurance from all subcontractors? Is there a Diary System in place to track expiration dates of certificates of insurance? Is the risk named as an additional insured on all subcontractors policies? Does the risk require all subcontractors to carry primary limits equal to or greater than their own? Does the risk use written subcontractor agreements with all subcontractors containing hold harmless/indemnify agreements in favor of the risk? Are subs hired subject to a formal written pre-qualification process? Attach a copy of the form Attach a copy of the subcontractor agreement the risk uses with all subcontractors. 22. Are safety meetings held on a quarterly basis; do managers, subcontractors and employees attend, and are attendance records kept? If less than quarterly, how often? 23. Does the risk have and architect or engineer on staff? If, does the risk carry professional liability insurance? If, does the risk require that the architect or engineer carry his/her
6 own professional liability insurance? 24. Trade association affiliation? IEC NECA 25. Is Hired & n-owned Auto coverage desired? If, how many drivers? Producer s Signature Date Applicant s Signature Title Date FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstances shall, dependent upon applicable statute, be grounds for imprisonment, fines or rescission of the insurance policy.
QSR Quaker Special Risk Exclusively serving retail agents since 1960
QSR Quaker Special Risk Exclusively serving retail agents since 1960 Masonry/Concrete/Plastering/Cement Contractors Specialty Trade Contractors Program Account Name Account Contact Name Producer Name Producer
More informationQSR Quaker Special Risk Exclusively serving retail agents since 1960
QSR Quaker Special Risk Exclusively serving retail agents since 1960 Alternative Energy Contractors Program Specialty Trade Contractors Program Account Name Account Contact Name Producer Name Producer
More informationContractors General Liability Application
SURPLEX UNDERWRITERS, INC. www.surplexuw.com SURPLEX UNDERWRITERS, PO BOX 998 PORTLAND, ME. 04104, FAX 207-856-0260, PHONE 800-441-1799 SURPLEX UNDERWRITERS, PO BOX 10477, BEDFORD, NH. 03110, FAX 603-625-4869,
More informationGENERAL CONTRACTORS APPLICATION
GENERAL CONTRACTORS APPLICATION Instructions 1. Please complete this application. All questions must be answered. (If None or Not Applicable so indicate) 2. If space is insufficient to complete answers,
More informationSUPPLEMENTAL QUESTIONNAIRE Artisan Contractors
SUPPLEMENTAL QUESTIONNAIRE Artisan Contractors GENERAL INFORMATION Applicant Name: Mailing Address: Location Address (if different from above): Website Address: Date Business Started Has applicant changed
More informationCONTRACTORS GENERAL LIABILITY APPLICATION (Other than E-Z Rate Contractors)
CONTRACTORS GENERAL LIABILITY APPLICATION (Other than E-Z Rate Contractors) PREQUALIFICATION (Refer to Contractors section of the Underwriting Guide for additional restrictions) 1. Are you involved (past,
More informationSitePro Supplemental Questionnaire
900 Route 9 North, Suite 503, Woodbridge, Website: www.nipgroup.com NJ 07095 Toll-free Phone: (800) 446-7647 SitePro Supplemental Questionnaire GENERAL INFORMATION Applicant Name: Mailing Address: Location
More informationContractors supplemental application
Contractors supplemental application MAGL 2005 08 16 Page 1 of 6 Contractors supplemental application (to be attached to ACORD applications) General contractor/artisan contractor Applicant information
More informationGeneral Contractors/Developers General Liability Application
General Contractors/Developers General Liability Application Applicant s Name Mailing Address Agency Name Agent Address Web Site Address E-Mail Phone PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard
More informationCONTRACTOR S SUPPLEMENTAL QUESTIONNAIRE
CoverX The Coverage Experts www.coverx.com FLORIDA 3050 NORTH HORSESHOE DRIVE, SUITE 200 NAPLES, FLORIDA 34014 (239) 430-9119 Telephone (239) 430-9416 Fax coverxfl@coverx.com Underwriting Email TEXAS 311
More informationGeneral Contractors/Developers General Liability Application
General Contractors/Developers General Liability Application ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE. Applicant s Name _ Agent Name Address Mailing Address PROPOSED EFFECTIVE
More informationContractors Application
Agency Name: Address: Contact Name: Phone: Fax: Email: Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING
More informationCONTRACTORS APPLICATION WESTCAP INSURANCE SERVICES, INC. 4. PRODUCER CONTACT NAME 6. PRODUCER
1. PRODUCER : 2. PRODUCER : 3. PRODUCER TELEPHONE: 5. PRODUCER FAX 7. APPLICANT 4. PRODUCER CONTACT 6. PRODUCER E-MAIL INDIVIDUAL PARTNERSHIP CORPORATION JOINT VENTURE LLC OTHER 8. APPLICANT STREET 9.
More informationQuaker Special Risk a division of Quaker Agency, Inc.
New Business Summary Worksheet Complete submissions help to expedite the underwriting and quoting process, as well as allow us to provide the most competitive and comprehensive terms available. Submissions
More informationROOFING CONTRACTOR QUESTIONNAIRE Ed. 9-09
ROOFING CONTRACTOR QUESTIONNAIRE Ed. 9-09 Applicant Name: Mailing Address: Location: Web Address: Agent s Name: Address: Proposed Effective Date: From: To: 12:01 A.M. Standard Time at the address of the
More informationCONTRACTORS SUPPLEMENTAL APPLICATION
Note: This application must be completed in addition to the ACORD Applicant Information Section and the Commercial General Liability Application. The signature of an owner, partner or officer is required
More informationContractors General Liability Supplemental Questionnaire
Contractors General Liability Supplemental Questionnaire Applicant Name: Mailing Address: Years in business under current name: 1. If this is a new operation, please provide details on prior experience
More informationGeneral Contractors/Developers General Liability Application
Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com General Contractors/Developers
More informationCONTRACTORS SUPPLEMENTAL QUESTIONNAIRE. Note: throughout this questionnaire the words you and your include all entities seeking coverage.
NAVIGATORS CALIFORNIA INSURANCE SERVICES, INC. 433 California Street, Suite 820, San Francisco CA 94104 Tel: (415) 399-9109 Fax: (415) 399-9468 License # 0785521 CONTRACTORS SUPPLEMENTAL QUESTIONNAIRE
More informationCONTRACTORS SUPPLEMENTAL APPLICATION
Mt. Hawley Insurance Company Peoria, IL 61615 CONTRACTORS SUPPLEMENTAL APPLICATION Applicants Instructions: Answer all questions. If the answer to any question is NONE, please state NONE. Application must
More informationGENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant
More informationGENERAL CONTRACTORS & PROJECT MANAGERS SUPPLEMENTAL APPLICATION
EVERGREEN INSURANCE MANAGERS INC License #: CA 0G35858 ID 146979 OR 100167092 WA 702962 www.evergreenins.com GENERAL CONTRACTORS & PROJECT MANAGERS SUPPLEMENTAL APPLICATION APPLICANT INFORMATION Applicant
More informationCONTRACTING OPERATIONS INFORMATION
t m CONTRACTOR S SUPPLEMENTAL QUESTIONNAIRE Note: Throughout this questionnaire the words you and your include all entities seeking coverage. BASIC INFORMATION Name(s) of Applicant: License Number: Years
More informationCONTRACTORS QUESTIONNAIRE
www.hullandco.com CONTRACTORS QUESTIONNAIRE ALL QUESTIONS MUST BE ANSWERED (Attach additional paper if necessary) 1. Applicant: A. Years in business under current name: B. Describe your operations: C.
More informationCONTRACTORS GENERAL LIABILITY APPLICATION
CONTRACTORS GENERAL LIABILITY APPLICATION PREQUALIFICATION 1. Are you involved (past, present or intended future) in residential construction (new, remodeling, installation or repair), and/or development
More informationCOLORADO CONTRACTORS QUESTIONNAIRE
COLORADO CONTRACTORS QUESTIONNAIRE ALL QUESTIONS MUST BE ANSWERED (Attach additional paper if necessary) 1. Applicant: A. Years in business under current name: B. Describe your operations: C. Do you currently
More informationR-T Specialty Insurance Services, LLC (Lic. # 0G97516) CONTRACTING RISK SUPPLEMENTAL QUESTIONNAIRE
R-T Specialty Insurance Services, LLC (Lic. # 0G97516) CONTRACTING RISK SUPPLEMENTAL QUESTIONNAIRE Note: Throughout this questionnaire the words you and your include all entities seeking coverage. 1. Applicant
More informationARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Mailing Address: Agency Name: Agent: Phone: PROPOSED EFFECTIVE DATE: From To
More informationYes No. 7. Risk is operating as: (Definitions of italicized terms are provided on the last page) General Contractor % Prime Contractor %
On-site waste treatment Operations conducted in an oil or natural gas producing field Pile driving for structure foundation Railroad construction Subway construction Septic system installation, service
More informationGeneral Contractors Supplemental Application
General Contractors Supplemental Application APPLICANT INFORMATION Applicant Name: AKA / DBA: Mailing Address: Loc Address: Area of Ops: Insured Contact: Website: Yrs in Business: Yrs Experience: Phone:
More informationGeneral Liability Supplemental Application
General Liability Supplemental Application Requested Policy Period: to INSURED INFORMATION Insured Name: DBA: Business Owners Name: (list all owners) Individual Partnership Corporation Other Contact: Mailing
More informationNew York Project Specific Application For Insurance
New York Project Specific Application For Insurance 1. Named Insured(s): 2. Name of Principal(s): 3. 4. Project Name: 5. Project Address: 6. Project Start Date: Project Completion Date: 7. Project Website:
More informationMt. Hawley Insurance Company CONTRACTORS SUPPLEMENTAL APPLICATION
Mt. Hawley Insurance Company CONTRACTORS SUPPLEMENTAL APPLICATION Applicants Instructions: Answer all questions. If the answer to any question is NONE, please state NONE. Application must be signed and
More informationARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm.
More informationCONTRACTORS QUESTIONNAIRE
CONTRACTORS QUESTIONNAIRE Applicant Name: Mailing Address: Agents Name: Address: Location: Proposed Effective : From: To: 12:01 A.M. Standard Time at the address of the Applicant Applicant Is: Individual
More informationCONTRACTORS GENERAL LIABILITY SUPPLEMENTAL APPLICATION
AGENT FIRST NAME: AGENT LAST NAME AGENT EMAIL: FIRST NAME: LAST NAME: DBA: BUSINESS NAME: BUSINESS TYPE: COUNTY: PRIMARY LOCATION ADDRESS: CITY: STATE: ZIP: MAILING ADDRESS: CITY: STATE: ZIP: WEB ADDRESS:
More informationNIF Insurance Services of California Artisan Pak New Business Qualifier - General Liability ( GL )
NIF Insurance Services of California Artisan Pak New Business Qualifier - General Liability ( GL ) a division of NIF Group, Inc. Phone: (916) 566-1000 P.O. Box 13456 submissions@nifcalifornia.com Sacramento,
More informationARTISAN/TRADE/RESIDENTIAL BUILDER S APPLICATION
ARTISAN/TRADE/RESIDENTIAL BUILDER S APPLICATION If operations are primarily one specific trade, refer to that trade s Supplement (e.g. Roofers). PREQUALIFICATION - Risk(s) are ineligible if they include
More informationGENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant s Name: Agency Name: Agent No.: Mailing Address: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy ADMITTED ARTISAN CONTRACTOR PROGRAM APPLICATION 5/24/2017 5/24/2017 Submission Number: Submission Type: New Renewal Conversion BROKER INFORMATION
More informationContractors Supplemental Questionnaire
Contractors Supplemental Questionnaire Insured to complete and sign questionnaire Policy No. Ownership/Operations 1. Company Name: 2. Mailing Address: 2a. Location Address if different than above: 3. Company
More informationNational Utility Contractors Association (NUCA) Supplemental Application Commercial Affiliation Marketing (CAM ) ELIGIBILITY
National Utility Contractors Association (NUCA) Supplemental Application Commercial Affiliation Marketing (CAM ) Account Name Account Contact Name Producer Name Producer e-mail address Account web site
More informationCompany Type: Corporation LLC Partnership Individual Joint Venture If Joint Venture, please describe: Additional Named Insured s (if any)
CONTRACTOR S POLLUTION LIABILITY APPLICATION SECTION 1 APPLICANT INFORMATION Applicant (Full Legal Name): Physical Address of Applicant: Mailing Address of Applicant: City: State: Zip Code: Established:
More informationIs Applicant: Individual Partner Corporation LLC Other: describe. Fax Number: Cell Number:
OREP/David Brauner Insurance Services 6760 University Ave., Suite 250, San Diego, Ca. 92115 Phone: 888-347-5273; Fax: 619-704-0567; Email: info@orep.org Date: Name of Applicant/Primary Owner(s): Company
More informationARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Agency Name: Mailing Address: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE:
More informationGENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
More informationCENTURY INSURANCE GROUP CONTRACTORS QUESTIONNAIRE AND WARRANTY General Agency
Notice: This application becomes part of the policy and must be signed in ink by the President or Owner of the Named Insured. Any coverage we issue is due to the reliance of the truth and accuracy of the
More informationSafety Program 1. Is there a formal written Safety Program in effect? 2. Are Regular safety meetings conducted? How Often? 3. Is there a Safety Commit
A Unit of Breckenridge Insurance Group 4000 S. Eastern Avenue, Suite 320 Las Vegas, NV 89119 CONTRACTORS ELITE QUESTIONNAIRE 1. PLEASE CAREFULLY READ THE STATEMENTS AT THE END OF THIS APPLICATION. 2. Answer
More informationBusiness Entity Individual Partnership Corporation LLC Other Contractor's License State/Number
Please include with this application: Five (5) years currently valued, legible loss runs; Resume of owner (required if start up or less than two years business history); List of major work completed in
More informationCONTRACTOR S SUPPLEMENTAL APPLICATION
CONTRACTOR S SUPPLEMENTAL APPLICATION Note: Throughout this questionnaire the words you and your include all entities seeking coverage. Name(s) of Applicant: Address: Years in Business*: Years Experience:
More informationCONTRACTORS GENERAL LIABILITY APPLICATION
CONTRACTORS GENERAL LIABILITY APPLICATION PREQUALIFICATION (Refer to Contractor or General Contractor SMART Cards in the Underwriting Guide for additional restrictions) 1. Are you involved (past, present
More informationOWNERS/CONTRACTORS PROTECTIVE LIABILITY APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com OWNERS/CONTRACTORS PROTECTIVE LIABILITY APPLICATION Name of Applicant/Owner:
More informationFORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Name of Applicant: Web site Address: State/Area of Operations: ANSWER ALL QUESTIONS IF
More informationCONTRACTORS APPLICATION
AS USED IN THIS APPLICATION, THE NAMED INSURED IS REFERRED TO AS APPLICANT OR YOU. AS USED IN THIS APPLICATION, IS THE 12 MONTH PERIOD FOR WHICH APPLICANT SEEKS TO BE COVERED BY THE GENERAL LIABILITY INSURANCE
More informationCONTRACTORS EQUIPMENT RENTAL GENERAL LIABILITY APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com CONTRACTORS EQUIPMENT RENTAL GENERAL LIABILITY APPLICATION Applicant
More informationCONTRACTORS LIABILITY APPLICATION CLAIMS MADE FORM
Minnesota Joint Underwriting Association 12400 Portland Ave S, Suite 190 Burnsville, MN 55337 1-800-552-0013 or 952-641-0260 Fax: 952-641-0274 www.mjua.org CONTRACTORS LIABILITY APPLICATION CLAIMS MADE
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy ADMITTED ARTISAN CONTRACTOR PROGRAM APPLICATION 3/30/2017 1/23/2017 Submission Number: Submission Type: New Renewal Conversion BROKER INFORMATION
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy ADMITTED ARTISAN CONTRACTOR PROGRAM APPLICATION 3/7/2017 1/24/2017 Submission Number: Submission Type: New Renewal Conversion BROKER INFORMATION
More informationGENERAL CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL. Dual Commercial LLC
GENERAL CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL Dual Commercial LLC APPLICANT INFORMATION: Applicant: Business Address: Contact Name: DBA: Mailing Address: Contact Ph Number: Email Address: AGENCY INFORMATION:
More informationFor Annual Policies:
CONTRACTORS POLLUTION LIABILITY FOR NON- ENVIRONMENTAL CONTRACTORS APPLICATION REQUIREMENTS For Annual Policies: 1. Contractors Pollution Liability Application - complete all questions in full. 2. Special
More informationARTISAN/TRADE/RESIDENTIAL BUILDER'S APPLICATION
ARTISAN/TRADE/RESIDENTIAL BUILDER'S APPLICATION If operations are primarily one specific trade, refer to that trade's supplemental application (e.g. Roofers). PREQUALIFICATION - Risk(s) are ineligible
More informationContractors Equipment Rental General Liability Application
Surplus Call 800-342-5706 Insurance Fax 800-578-7758 www.surplusins.com Brokers Email quotes: submit@surplusins.com Agency Inc. P O Box 749, South Bend IN 46624-0749 Contractors Equipment Rental General
More informationFORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Mailing Address: Agency Name: Agent No.: Phone No.: PROPOSED EFFECTIVE
More informationArtisan Contractors Application
Artisan Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING ADDRESS AGENT / PRODUCER INFORMATION APPLICANT
More informationEXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
More informationGENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01
More informationOwner s/tenant s Protective Product
USLI.COM 888-523-5545 Owner s/tenant s Protective Product OWNER S/TENANT S PROTECTIVE PRODUCT APPLICATION Please complete all sections of this application and have signed by the applicant. NOTE: Products/Completed
More informationIncomplete submissions will be declined
MOLD REMEDIATION CONTRACTORS APPLICATION REQUIREMENTS 1. Contractors Pollution Liability Application and Acord 125 & 126 applications - complete all questions in full. 2. Special attention should be paid
More informationGENERAL CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL
GENERAL CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL APPLICANT INFORMATION: Applicant: Business Address: Contact Name: DBA: Mailing Address: Contact Ph Number: Email Address: AGENCY INFORMATION: Agency name:
More informationProject Specific Application For Insurance
Project Specific Application For Insurance I. GENERAL INFORMATION: II. Named Insured(s): Mailing Address: Project Name: Project Address: Project Start Date: Project Completion Date: Has Financing Been
More informationPLEASE LIST ALL OTHER LOCATIONS ON ACORD FORM
Agency: Producer: Phone: Fax: Email: Policy Effective Date: FEIN#: DOT#: Name Insured: DBA (if applicable): Mailing Address: Any Filings Needed: Garage Zip Code: County: What States do you operate in?
More informationCONTRACTOR S POLLUTION LIABILITY INSURANCE APPLICATION
CONTRACTOR S POLLUTION LIABILITY INSURANCE APPLICATION INSTRUCTIONS Please complete all sections. If any section does not apply, indicate with N/A. Attach additional pages if needed. This application must
More information1. Proposed Effective Date 2. Proposed Expiration Date 3. Today s Date
PAGE 1 OF 6 1. Proposed Effective Date 2. Proposed Expiration Date 3. Today s Date 4. Name of Applicant and/or corporate name (use separate sheet it more space is needed): 5. Mailing Address: STREET CITY
More informationPlease list all branch offices on a separate sheet and include a breakdown of the staff at each location.
ARCHITECTS & ENGINEERS PROFESSIONAL LIABILITY APPLICATION ITECTS & ENGINEERS PROFESSIONAL LIABILITY APPLICATION GENERAL INFORMATION 1. Company Name (Applicant): CH Street: City: State: Zip: Telephone:
More informationProducer: Producer Is: Wholesaler Retailer Address: ROOFING CONTRACTOR SUPPLEMENTAL APPLICATION
CoverX The Coverage Experts www.coverx.com FLORIDA 3050 NORTH HORSESHOE DRIVE, SUITE 200 NAPLES, FLORIDA 34014 (239) 430-9119 Telephone (239) 430-9416 Fax coverxfl@coverx.com Underwriting Email TEXAS 311
More informationContractors Equipment Rental General Liability Application. Agency Name: Agent: Address: Phone No.:
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com Contractors Equipment Rental General Liability
More informationRENEWAL APPLICATION CONTRACTORS AND CONSULTANTS
Please submit the following information: 1) Two years financials including balance sheet and income statement. 2) At least 3 yrs loss runs (not including those years written with Berkley Specialty Underwriting
More informationCONTRACTORS POLLUTION LIABILITY APPLICATION
CONTRACTORS POLLUTION LIABILITY APPLICATION SECTION I: APPLICANT NAME OF APPLICANT ADDRESS CITY STATE ZIP TELEPHONE WEB ADDRESS DATE Company is an: INDIVIDUAL PARTNERSHIP CORPORATION JOINT VENTURE OTHER
More informationCompany Type: Corporation LLC Partnership Individual Joint Venture
ENVIRONMENTAL CONTRACTOR & CONSULTANT APPLICATION SECTION 1 APPLICANT INFORMATION Applicant (Full Legal Name): Mailing Address of Applicant: City: State: Zip Code: Telephone: Website: Environmental Contact
More informationMAILING ADDRESS CITY STATE ZIP CODE PHYSICAL ADDRESS IF DIFFERENT CITY STATE ZIP CODE CONTACT NAME CONTACT CONTACT PHONE # WEBSITE ADDRESS
CIU APPLICATION DATE NEED BY DATE PROPOSED EFFECTIVE DATE 901 E Saint Louis St Ste 205 Springfield MO 65806-2537 1-800-241-9759 Fax: 877-203-0291 newbusiness@ciusgf.com SECTION A: APPLICANT INFORMATION
More informationFORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION
More informationDEMOLITION CONTRACTORS (PER JOB BASIS) GENERAL LIABILITY APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com DEMOLITION CONTRACTORS (PER JOB BASIS) GENERAL LIABILITY APPLICATION
More informationARCHITECTS & ENGINEERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION
Hartford Financial Products Architects & Engineers Department Administrative Office: 2 Park Avenue, New York, NY 10016 Website: www.thehartford.com ARCHITECTS & ENGINEERS PROFESSIONAL LIABILITY INSURANCE
More informationINSENTIAL ROOFERS PROGRAM
INSENTIAL ROOFERS PROGRAM Overview Access the best markets for your commercial and residential roofing clients with Insential insurance solutions. We have the expertise you need. We have been writing roofers
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy ADMITTED ARTISAN CONTRACTOR + INLAND MARINE PROGRAM APPLICATION 3/15/2017 3/15/2017 Submission Number: Submission Type: New Renewal Conversion
More informationResidential/Commerical General Contractors Application
Residential/Commerical General Contractors Application Named Insured: Address: City: State: Zip: Company Website: Structure of Organization: Corporation Partnership Sole Proprietorship LLC If other, please
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy GENERAL INFORMATION ADMITTED ARTISAN CONTRACTOR PROGRAM APPLICATION Submission Number: Submission Type: New Renewal Conversion BROKER INFORMATION
More informationCONTRACTORS PROJECT-SPECIFIC POLICY SUPPLEMENTAL Tel: (847) West High Street, Somerville, NJ
CONTRACTORS PROJECT-SPECIFIC POLICY SUPPLEMENTAL Tel: (847) 208.8847 198 West High Street, Somerville, NJ 08876 www.axonu.com NOTE: THIS IS AN APPLICATION FOR A PROJECT-SPECIFIC POLICY OR ENDORSEMENT This
More informationCONTRACTORS APPLICATION
AS USED IN THIS APPLICATION, THE NAMED INSURED IS REFERRED TO AS APPLICANT OR YOU. AS USED IN THIS APPLICATION, IS THE 12 MONTH PERIOD FOR WHICH APPLICANT SEEKS TO BE COVERED BY THE GENERAL LIABILITY INSURANCE
More informationROOFERS QUESTIONNAIRE (COMPLETE IN ADDITION TO GL APPLICATION)
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com ROOFERS QUESTIONNAIRE (COMPLETE IN ADDITION TO GL APPLICATION) Applicant
More informationDemolition Contractors Annual Policy General Liability Application
Demolition Contractors Annual Policy General Liability Application Agency Name: Agent: Phone number: Address: City/State: Zip code: E-mail address: Fax number: Applicant s Name: APPLICANT INFORMATION Street
More informationREAL ESTATE PROPERTY MANAGEMENT SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com REAL ESTATE PROPERTY MANAGEMENT SUPPLEMENTAL APPLICATION (Complete
More informationFire Sprinkler Contractor General Liability Application
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
More informationContractors, Design-Builders and Construction Consultants Contractors Professional Liability and Pollution Incident Liability
Contractors, Design-Builders and Construction Consultants Contractors Professional Liability and Pollution Incident Liability THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. This Application
More informationThe Cincinnati Insurance Company The Cincinnati Casualty Company The Cincinnati Indemnity Company CINCINNATI CONTRACTORS SUPPLEMENT
The Cincinnati Insurance Company The Cincinnati Casualty Company The Cincinnati Indemnity Company CINCINNATI CONTRACTORS SUPPLEMENT Applicant Name: New Renewal Policy Number: Type of Contractor: Years
More informationTELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant s Name: Agent Name: Agent Address: Location Address: Phone No.: PROPOSED EFFECTIVE
More informationSubmission Type: New Renewal Conversion BROKER INFORMATION
Proposed Effective Date Expiration Date of Current GL Policy ADMITTED ARTISAN CONTRACTOR + INLAND MARINE PROGRAM APPLICATION 4/22/2017 4/22/2017 Submission Number: Submission Type: New Renewal Conversion
More informationJames River Insurance Company and its Subsidiaries
James River Insurance Company and its Subsidiaries 6641 West Broad Street, Suite 300 Richmond, VA 23230 Application for Environmental Contractors Pollution Liability Environmental Division Email to EV@jamesriverins.com
More informationTELECOMMUNICATION CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 1-800-423-7675 Fax (480) 483-6752
More informationCONTRACTORS POLLUTION LIABILITY APPLICATION
CONTRACTORS POLLUTION LIABILITY APPLICATION THIS IS AN APPLICATION FOR EITHER A CLAIMS-MADE OR OCCURRENCE FORM POLICY All questions must be answered completely. If space is insufficient to complete answers
More information